Provider Demographics
NPI:1386619492
Name:RODA, JAN (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:RODA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E 58TH ST
Mailing Address - Street 2:27TH FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10155
Mailing Address - Country:US
Mailing Address - Phone:212-752-8919
Mailing Address - Fax:212-588-9721
Practice Address - Street 1:150 E 58TH ST
Practice Address - Street 2:27TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10155
Practice Address - Country:US
Practice Address - Phone:212-752-8919
Practice Address - Fax:212-588-9721
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1742732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01421094Medicaid
48F232Medicare ID - Type Unspecified
NY01421094Medicaid